Category: Coding

02 May 2017

Fecal microbiota transplant: Procedure and coding guidelines

Fecal Transplant - Procedure and coding guidelines1

Fecal transplantation is a procedure performed for patients suffering from recurrent infections by a type of bacteria called Clostridium difficile. The infection is spread through contact with surfaces contaminated by spores of the bacterium. The range of symptoms include diarrhea, pseudomembranous colitis, fever, nausea and abdominal pain.

In recent times, there has been an increased antibiotic resistance for C. difficile. Fecal bacteriotherapy or stool transplant is an emerging technique for treating patients suffering from such antibiotic resistance.

The procedure
Fecal microbiota transplant (FMT) involves transplantation of fecal microbiota collected from a healthy individual into the gut of patient. The donor’s stool sample is carefully screened and selected for transplant.

A close relative may prove to be suitable donor however, non relatives stool samples may also be effective.

Fresh stools are often used for preparation of an infusion. Once ready, the infusion is administered by means of enema using a colonoscope or through a nasogastric tube.

Indications for the therapy
• Clostridium difficile infection

Coding guidelines

For Medicare:
CPT code to be reported – G0455 – Preparation with instillation of fecal microbiota by any method, including assessment of donor specimen

(Medicare does not pay a separate fee for the installation of the microbiota by oro-nasogastric tube, enema, or by upper or lower endoscopy)

ICD-10 codes that can be reported:

Z20.9 – Contact with and (suspected) exposure to unspecified communicable disease

Z22.1 – Carrier of other intestinal infectious diseases

Z11.59 – Encounter for screening for other viral diseases

Z11.3 – Encounter for screening for infections with a predominantly sexual mode of transmission

Z11.2 – Encounter for screening for other bacterial diseases

Z11.0 – Encounter for screening for intestinal infectious diseases

Z11.8 – Encounter for screening for other infectious and parasitic diseases

Z11.9 – Encounter for screening for infectious and parasitic diseases, unspecified

For commercial payors:
44705 – Preparation of fecal microbiota for instillation, including assessment of donor specimen
44799 – Fecal instillation by oro-nasogastric tube or enema (This CPT code is used to indicate  instillation).

Do not report 44705 in conjunction with 74283 (Therapeutic enema, contrast or air, for reduction of intussusception or other intraluminal obstruction (e.g., meconium ileus)

Have a coding question? Let me know in the comments below.

The information is presented for educational use only. It is not meant to be used to diagnose or treat any medical condition. We have made all reasonable efforts to ensure the information provided in this guide is accurate at the time of inclusion, however, please resort to clinical documentation and your experience to make decisions while coding and billing for procedures.

By Sandeep Paranjape, NextServices

07 Mar 2017



Remembering codes with so many permutations and combinations can be really overwhelming. To help you understand and code better, we have created this reference guide which you can refer to code and bill accurately for your next case. Guide includes CPT Codes for Colonoscopy, Esophagoscopy, EGD, Enteroscopy, ERC and Sigmoidoscopy.




October 1st, 2016 marked the end of the grace period allotted by CMS and AMA to facilitate smooth ICD-10
implementation. During the grace period, insurances processed claims even if they were wrongly coded, just as
long as the codes belonged to the broader family of correct codes. However, such claims will not be paid after
the grace period. It now becomes crucial for medical practices to strictly adhere to ICD-10 coding guidelines to
avoid payment disruptions.

Guide includes ICD-10 Coding guidelines for screening and surveillance colonoscopy.



Disclaimer – The information is presented for educational use only. It is not meant to be used to diagnose or treat any medical condition. We have made all reasonable efforts to ensure the information provided in these guides are accurate at the time of inclusion, however, please resort to clinical documentation and your experience to make decisions while coding and billing for procedures.

Our new book Private Equity in Gastroenterology – Navigating the Next Wave is still available for download. Here was the best compliment we got to date: “I need my entire board to read this!”


18 Feb 2017

How to code for ulcers according to ICD-10 guidelines

With ICD-10, reporting for type, occurrence site, and complication has dramatically increased coding complexity. There are codes ranging from problems in relationship with in-laws (Z63.1) to being pecked by a chicken (W61.33) to being bitten by a sea lion (W56.11)!

Ulcer is one of the most frequently reported diagnosis codes in gastroenterology. However, with the advent of ICD-10, coding for the simple diagnosis has become complicated for even the most experienced doctors.

To make your life a little easier, we compiled a list of accurate coding guidelines for ulcers that you could refer to for your next case.

Ulcers are broadly classified based on the organ they are present.

1) Gastric ulcer (K25)

2) Duodenal ulcer (K26)

3) Peptic ulcer (K27)

4) Gastrojejunal ulcer (K28)

Each type of ulcer is further classified into acute or chronic. If the nature of ulcer cannot be determined, an “unspecified” code may be used.

Coding now goes up to the 4th level (or the fourth digit of ICD-10 code) of specificity. Each type of ulcer is coded with reference to the complications associated with it. For example, the code used for Acute gastric ulcer with hemorrhage would be K25.0

The ICD-10 CM manual also instructs the use additional codes if the patient is diagnosed with alcohol abuse and dependence.

F10 is the ICD-10 code for alcohol related disorders which is classified further into alcohol abuse (F10.1), alcohol dependence (F10.2), alcohol use, unspecified (F10.9). The F10 code can be further specified by the use additional codes. For example, blood alcohol level measurement is Y90.

Let’s understand this using a patient scenario:

Joan, age 36 years, presented with abdominal pain, nausea, vomiting and melena. She was scheduled for EGD after unsatisfactory PPI treatment. EGD revealed acute duodenal ulcer which was bleeding along with perforations. She consumes alcohol every day and shows withdrawal delirium. Her blood alcohol levels were 72 mg/100ml.

The coding for this scenario would be as follows:

Primary code: K26.2 (because the type of ulcer is duodenal and it is acute with hemorrhage and perforation)
Secondary code: F10.231 (because she exhibits alcohol dependence with withdrawal delirium)
Tertiary code: Y90.3 (because of the range of her blood alcohol level is 60-79 mg/100 ml)

This is how you think in an ICD-10 world. More specifically.

Below are coding guidelines in a tabulated format:

How to use this table:

The (*) mark specifies the nature of the condition.

For example, if an ulcer is duodenal, is acute and hemorrhage is present – the code to use would be K26.0

Another example, if an ulcer is peptic, is chronic/unspecified and hemorrhage is present – the code to use would be K26.4

Correct coding practices are the backbone for clean claims. Submitting clean claims with high first-pass ratio bring predictability in reimbursements. Pay attention to the levels of specificity that ICD-10 demands.

Have you come across any unique coding scenarios? Let me know in the comments below.


By Sandeep Paranjape, NextServices


[FREE GUIDE] How to bill accurate codes for endoscopy procedures

Adhere to ICD-10 coding guidelines now [avoid payment disruptions]


21 Jul 2016

Adhere to ICD-10 Coding Guidelines Now [avoid payment disruptions]

October 1st, 2016 marks the end of the grace period allotted by CMS and AMA to facilitate smooth ICD-10 implementation. During the grace period, insurances processed claims even if they were wrongly coded, just as long as the codes belonged to the broader family of correct codes. However, such claims will not be paid after the grace period. It now becomes crucial for medical practices to strictly adhere to ICD-10 coding guidelines to avoid payment disruptions.

Here are a few guidelines for screening and surveillance colonoscopy.

Difference between screening and surveillance colonoscopies
Screening is a test provided to a patient in the absence of signs or symptoms. A screening colonoscopy is a service performed on an asymptomatic person for the purpose of testing the presence of colorectal cancer or colorectal polyps.
A surveillance colonoscopy can be performed at varying ages and intervals based on the patient’s personal history of colon cancer, polyps, and/or gastrointestinal disease. For example, patients with a history of colon polyps are not recommended for a screening colonoscopy, but for a surveillance colonoscopy.

Coding guidelines
ICD-10 guidelines clearly demarcate between coding for screening and surveillance.

Screening for malignant neoplasm of  ICD-10 code
Stomach Z12.0
Intestinal tract, unspecified Z12.10
Colon Z12.11
Rectum Z12.12
Small intestine Z12.13
Other sites Z12.89
Site unspecified Z12.9
Non cancerous disorders ICD-10 code
Screening for upper GI disorder Z13.810
Screening for lower GI disorder Z13.811
Screening for other digestive disorders Z13.818


Additional codes for family history of malignant neoplasm

Z80.0 –   Family history of malignant neoplasm of digestive organs

Z83.71 – Family history of colonic polyps

Z83.79 – Family history of other diseases of the digestive system


Surveillance colonoscopy codes

Z08 – Encounter for follow up examination after completed treatment of malignant neoplasm.
Use additional code for personal history of malignant neoplasm (Z85.-)

Organ Malignancy ICD-10 Code
Stomach Carcinoid tumor Z85.020
Other malignant neoplasm Z85.028
Large intestine Carcinoid tumor Z85.030
Other malignant neoplasm Z85.038
Rectum, rectosigmoid junction, anus Carcinoid tumor Z85.040
Other malignant neoplasm Z85.048
Liver Malignant neoplasm Z85.05
Small intestine Carcinoid tumor Z85.060
Other malignant neoplasm Z85.068
Pancreas Malignant neoplasm Z85.07
Other digestive organs Malignant neoplasm Z85.09

Z09 – Encounter for follow up examination after completed treatment for conditions other than malignant neoplasm.

[Read: Choosing between Modifier 53 and 52 – Gastroenterology example]

Additional codes to identify any applicable history of diseases (Z86.-, Z87.-)

Z86.010 – Personal history of colonic polyps
Z86.012 – Personal history of benign carcinoid tumor
Z86.018 – Personal history of other benign neoplasm
Z86.03 – Personal history of neoplasm of uncertain behavior
Z86.19 – Personal history of other infectious and parasitic diseases.
Z87.11 – Personal history of peptic ulcer disease
Z87.19 – Personal history of other diseases of digestive system

Colonoscopies account for majority of a gastroenterologist’s revenues. It’s important that doctors and their coders pay close attention to the specificity that ICD-10 demands. Systems like enki EHR help in directing doctors to code correctly at the point of care.


[FREE GUIDE] How to bill accurate codes for endoscopy procedures

How to code for ulcers according to ICD-10 guidelines

16 Apr 2016

Your Medicare billing is now public through Treatment Tracker


Treatment Tracker, a tool released by ProPublica (an independent, investigative, non-profit newsroom), now reveals how doctors in the country (any doctor) coded for the 46 million Medicare patients in 2012. Medicare paid for more than 200 million office visits in that year and now that data is available for all to see. It provides amazing insight – for example, 1,800 providers billed high codes 90% of the time, bringing into a unique form of public scrutiny.

The tool allows you to drill down by each physician and provides her rank within a state and specialty, the number of services she has performed, total and average payments by Medicare and how she has coded overall. It further provides information about each of the procedures billed to Medicare, # of unique visits by patients on whom the procedure was performed and so on.

What physicians who are letting their EHRs code for them are not realizing is this: by allowing the system to suggest codes (often higher codes) based on clicks over Physical Exam, Review of Systems and templatized SOAP and operative notes, they would need to be prepared to future public scrutiny that would peg them with peers across their county, state and the whole country. Imagine this in the context of ALL the data provided to CMS via Meaningful Use.

Welcome to the world of big and open data!

09 Apr 2016

Focus and cut costs to thrive in Ambulatory Surgery Center market

Focus and cut costs

Since 2010, the ambulatory surgery center (ASCs) market has neither grown nor declined. ASCs start, shut-down and acquire other ASCs. There are over 5,400 surgery centers. Available physicians are limited and hospitals continue to pose a strong competition – sometimes partnering with ASCs. According to arecent Becker’s ASC article, ASCs will need to excel in a single specialty and run a very low cost center model to sustain in the future.


There are three dominant specialties in the ASC market: orthopedics, gastroenterology and ophthalmology. Let’s the example of ASC centers focused on gastroenterology. As medical science advances and a greater number of newer procedures become eligible for insurance reimbursement, gastroenterologists must develop deeper focus within the specialty. In 2014, there are 26 new codes for gastroenterology – suggesting newer ways to focus, get reimbursed and build expertise. A group must focus on EUS, another on EGD or esophagoscopy and so on. This method of divide and conquer would allow an ASC to be known as a leader in the field within their market and at the same time cover a wide range of procedures within the specialty.

ASCs can further add plans that involve diet and exercise, virtual follow-ups for a monthly fee. This creates additional revenue streams based on deeper understanding of patients and their conditions. It also engages patients and their families better and brings them back to the center on a regular basis.

Cut costs

Outsourcing activities or tasks in a controlled and methodical manner is clearly a way to bring costs of administrative tasks down. Identify tasks that are lower on the complexity scale and delegate and outsource them. When they aren’t core to the business model (i.e., treating patients), tasks such as billing, coding, denial management, patient collections, accounting, credentialing, pre-authorizations and so on will tend to be distractions from the core focus of the surgery center. Outsourcing companies centralize operations for a large number of providers, giving them benefits of scale – these cost savings are typically passed on to the center that could then pass them on to patients.

According to the ASC Value Driver Survey, 24% of ASCs experience stable volume, 27% reported growing volume and 27 percent declining volume. In the same survey, respondents cited competition from other ASCs and hospitals as one of their biggest challenges. Clearly, it’s a time to focus and cut costs to stay competitive.

09 Apr 2016

How to code for optical endomicroscopy? (an optical biopsy)


What is it?

This technique involves use of optical technology to see enlarged view of cell, tissues in real time. It is also called Optical Biopsy. The doctor uses a probe, which is used to view the cellular structures in the organ concerned. It is found to be useful in:

  1. Barrette’s esophagus in detecting dysplastic lesions.
  2. In early detection of gastric cancer and intestinal metaplasia.
  3. Detection of malignant bilio-pancreatic strictures.
  4. Diagnosis of pancreatic cysts.
  5. Inflammatory bowel disease.
  6. Helps to differentiate between neoplastic and non neoplastic tissue.
  7. Detecting residual neoplasia after concerned tissue removal.


The year 2013 saw the allocation of two CPT codes: 

43206 – Esophagoscopy with optical endomicroscopy.

43252 – EGD with optical endomicroscopy.

These procedures cannot be reported with other endoscopy procedures. They are reported as separate and distinct procedures.


43206 and 43252 attracted an average payment of $149 & $186 respectively in a facility setting.

09 Apr 2016

What does it mean that 25% of ALL coding changes are related to Gastroenterology?


American Medical Association (AMA) added 175 new codes, revised 107 CPT/ procedure codes this year – 25% of them are related to gastroenterology (26 new codes, 41 revised codes and 17 deleted codes). Let’s consider an example.

If a patient showed up with a tumor in her esophagus, a gastroenterologist typically performs an esophagoscopy using snare technique to remove the tumor. A new technique has been doing the rounds during the past few years called Endoscopic Mucosal Resection (EMR) – it uses a suction mechanism to yank the tumor out from the skin before it’s cut. The technique helps in controlling unnecessary bleeding. Up until this year, EMR had no code. But this year, AMA recognized it with  43211 – a new code.

Up until this year, it didn’t matter whether a gastroenterologist used a flexible/ rigid scope or went in through the nose/ mouth during an esophagoscopy. But with the coding changes, it matters now – there’s increasing specificity.

What do examples of such coding additions/ changes mean for gastroenterology? At a very broad level, it simply means that there’s a shift underway. The patients are the same, the disease conditions are similar but how something can be diagnosed and treated is actively undergoing a change. Ambulatory surgery centers consider traditional upper and lower GI procedures as their bread and butter. But with steady innovation, better understanding and wider spread of newer techniques, the specialty will become even more specialized. Traditional procedures will continue to see declining reimbursements.

Knowing what we know of medicine, as procedures become mainstream, reimbursements decline and newer techniques become the preferred approach. It may be entirely possible that EMR may replace traditional esophagoscopy in the future. What if enough artificial intelligence algorithms may be built in to identify polyps from a video produced by a Video Capsule Endoscopy? What if the algorithms identify all possible polyps big and small throughout the digestive tract? Such thorough and extreme accuracy would be impossible with traditional colonoscopy that involves human hands and eyes. What would happen then to doctors who are not used to learning or experimenting with new procedures?

It’s also expected that in 2015, there would be lower gastroenterology coding changes. These coding changes are simply an acceptance of newer methods to treat and fix conditions and also a gentle nudge to gastroenterologists to stay current in their fields.

By Praveen Suthrum, President & Co-Founder, NextServices

09 Apr 2016

Esophagoscopy coding changes in 2014


Upper gastroenterology coding has seen important changes since Jan 1, 2014 – particularly, esophogoscopy procedures. Separate codes have been introduced for rigid esophagoscopy and flexible esophagoscopy.

Six new procedure codes have made an entry for rigid esophagoscopy this year. However, these codes are to be used only when esophagoscopy is done via the transoral route. In 2013, there were no separate codes for rigid transoral esophagoscopy – rigid or flexible esophagoscopy were included under the same definitions. In 2014, the specificity has increased based on the route of administration of scope i.e., transoral or transnasal and on whether the scope used was flexible or rigid.

If a rigid scope was used, the following new codes may be applied for the transoral route:

43191 – Rigid transoral e1sophagoscopy, diagnostic, brushing and washing. By using rigid scopes, procedures such as submucosal injections, biopsy, foreign body removal, balloon dilation, guide wire insertion and dilation over guide wire can be performed. CPT codes from 43192 through 43196 have been created to be used for these procedures.

If a flexible scope is used, but the route of administration is transnasal, these codes may be used:

43197 – Flexible transnasal esophagoscopy, diagnostic, brushing washing.

43198 – Flexible transnasal esophagoscopy, with biopsy.

Certain terminologies with respect to esophagoscopy have been revised. For e.g. CPT code 43200 is defined as ‘flexible’ (in 2014) as against ‘rigid or flexible’ (in 2013). CPT codes from 43200 through 43232 are now termed as flexible. The other specifications of the code descriptor remain the same.

New codes for Flexible Transoral Esophagoscopy

43211 – Flexible transoral esophagoscopy, mucosal resection. Till 2014, esophageal mucosal resection was reported by using unlisted codes 43499 (unlisted procedure, esophagus).

43212 – Flexible transoral esophagoscopy, stent placement, dilation and guide wire passage.

A new concept has been introduced, flexible transoral esophagoscopy with retrograde dilation with CPT code 43213.

43214 – Flexible transoral esophagoscopy, balloon dilation, including imaging. The imaging has been included effective 2014. Till 2014, imaging if performed had to be separately reported.

43229 – Flexible transoral esophagoscopy, with ablation, dilation and guide wire passage. This code now includes balloon dilation (43220), insertion of guide wire (43226) and ablation (43228).

By Sandeep Paranjape, Clinical and Coding expert, NextServices

09 Apr 2016

How does the auditor deny claims?

They are the scrutinizers. The claim sniffers. They are the auditors. Have you ever thought of why your claims are denied or paid? Is there a really smart computer or a human face behind that hits to go or the no-go button? It’s both. When you submit claims, they go through some really intelligent computer programs. These programs process each claim and flag irregularities. These red flags are then extensively analyzed by claim auditors.

Traces an auditor looks for.
Auditors compare the submitted claims against quality benchmarks that insurances set. These include claims coding analysis, modifier usage analysis, insurance and regulatory compliance, visit and health record documentation. Alternatively, they look for trends. For example, a frequent trend is duplicate claims submission.

Consequences of audit.
If any discrepancies are detected, auditors deny the claim. In cases where payments have been made, recoupment follows the audit.

Recommendations by auditors.
1. Follow ethical coding guidelines while submitting the claims.
2. Take into account the compliance guidelines laid down by the insurances.
3. Avoid malpractices for higher reimbursements.

As an auditor, before hitting the pay button I think of denial. I look into all aspects – coding, billing, eligibility, benefits and most of the claims have some or the other loophole which helps me deny the claim. I have always been taught – its your check book & you are making the payment on claim.
– Anonymous auditor (name withheld)

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